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Prednisone for copd exacerbation. Controlled trial of oral prednisone in outpatients with acute COPD exacerbation |
- Different Durations of Corticosteroid Therapy for COPD Exacerbations | AAFP
Is It Safe to Start Steroids at Home for a COPD Exacerbation After Virtual Assessment? – Consult QD.
Another reason may be that there are fewer COPD exacerbations due to less air pollution because people are working from home and not traveling as much.
Also, patients with chronic cough can be reflexively suspected of having COVID, and in-office visits are sometimes discouraged based on the infectious risk. Together, these factors have made virtual visits a mainstay of managing patients with COPD during the pandemic. Virtual visits have provided a portal for healthcare access while mitigating infection risks. They can allow one to form a clinical impression and to decide whether the patient needs emergent, in-person care versus continued virtual management.
Though studies have examined the value of self-management strategies for COPD with online and telephonic backup, 5 to our knowledge no published report has specifically addressed best practices in virtual visit assessment of patients with COPD. A careful history is important to elicit a history of exposure to individuals known to have SARS-CoV-2, and also to assess whether the current illness resembles prior exacerbations the patient may have experienced.
Visual inspection is critical and plays an even more important role during a virtual visit. Because corticosteroids are indicated in acute exacerbations of COPD, the current case prompts two questions:. Notably, prednisone 40 mg is roughly equivalent to dexamethasone 6 mg in glucocorticoid potency, though the duration of treatment for a COPD exacerbation five days is less than that for severe COVID disease up to 10 days.
The patient was started on oral prednisone 40 mg for five days for what was presumed to be an acute exacerbation of COPD. On follow-up one week after the initial virtual visit, his symptoms had dramatically improved, and he reported being back to his usual state of health. But despite the limitations, taking a systematic approach to the history and maximizing visual assessment, as with this patient, can help the patient safely get through the acute illness.
Although the efficacy of virtual visits has not been established for patients with COPD in general nor for those experiencing an exacerbation that might resemble COVID, this experience supports the value of virtual visits, coupled with a careful history and clinical observation during the visit. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease.
One study used antibiotics only if indicated by certain clinical features. The effect of co-interventions was not included in this review.
Five studies used oral prednisolone, one study used intravenous methylprednisolone, and two studies used a combination of oral and intravenous corticosteroids. Shorter courses of corticosteroids ranged from three to seven days of treatment; longer courses ranged from 10 to 15 days. This review did not discuss whether three days of treatment is equivalent to other courses of up to seven days of treatment.
The studies included only patients with severe to very severe COPD, although the criteria for this were not well-defined or consistent among studies. Three studies used pulmonary function testing diagnostic criteria, but even those criteria were not uniform. Primary outcomes included treatment failure, relapse after treatment, and adverse drug effects.
There was no difference in any primary outcomes between patients who were treated with systemic corticosteroids for seven or fewer days and those who were treated for more than seven days. The investigators rated the evidence for primary outcomes as moderate, with imprecision as a reported limiting factor.
Current guidelines from the Global Initiative for Chronic Obstructive Lung Disease recommend treating acute exacerbations of COPD with oral prednisone, 40 mg per day for five days in most patients. This content is owned by the AAFP. There is no evidence that treatment with corticosteroids alters mortality.
Unlike earlier reviews this review included four papers that compared intravenous corticosteroids with oral corticosteroids and two papers with ventilated patients in ICU. In patients requiring ventilation in ICU, pooled data did not show a reduction in length of stay, duration of ventilation or mortality in those receiving corticosteroids compared with placebo Walters Walters et al concluded that there is no evidence of benefit for intravenous treatment compared with oral treatment with corticosteroids on treatment failure, relapse or mortality.
Hyperglycaemia rates were higher with intravenous corticosteroids. With regards to duration of treatment, a meta-analysis by Walters et al Walters concluded that five days of oral corticosteroids is likely to be sufficient [evidence level I].
❾-50%}Prednisone for copd exacerbation.
The choice of the antibiotic should be based on the local pattern of bacterial resistance. Studies support the use of antibiotics when the patient has signs of bacterial infection. The recommended length of treatment is 5 to 10 days. Titrated oxygen is associated with less acidosis, a lower need for ventilation, and reduced mortality compared with the use of high-flow oxygen during exacerbations. Ventilatory Support: Some patients may require noninvasive nasal cannula or facial mask or invasive orotracheal tube or tracheostomy ventilatory support in order to maintain proper oxygenation.
Criteria for the use of noninvasive ventilation and invasive mechanical ventilation are given in TABLE 2. It may be appropriate to allow a trial of noninvasive methods prior to advancing support, as these modalities are associated with improvement in clinical signs, a decreased need for escalation to invasive mechanical ventilation, and reduced mortality. Although ventilatory support may seem necessary, it is important to take patient preferences into consideration and to be mindful of the risks.
There is not an established optimal length of hospitalization for patients with COPD exacerbations. Prior to discharge, patients should be clinically stable for a minimum of 12 to 24 hours and should need inhaled short-acting beta 2 -agonists no more than every 4 hours.
A plan for effective home management and follow-up should be coordinated and clearly communicated to the patient and his or her caregivers and healthcare providers. It is imperative that discharge planning include medication counseling to ensure patient and caregiver comprehension and proper medication use. Despite efforts to prevent COPD exacerbations, the rate of readmission remains quite high, which has caught the attention of the Joint Commission and the Centers for Medicare and Medicaid Services in recent years.
The frequency and severity of COPD exacerbations have been associated with poor prognosis and increased mortality. Pharmacists can counsel patients about how to prevent future COPD exacerbations, including disease education, smoking cessation, pneumococcal and annual influenza vaccinations, and proper inhaler technique for maintenance therapy.
Chronic obstructive pulmonary disease. National Institutes of Health. Fact sheet: chronic obstructive pulmonary disease COPD. Accessed February 21, World Health Organization. Chronic obstructive pulmonary disease fact sheet.
Accessed February 20, Gender differences in COPD: are women more susceptible to smoking effects than men? COPD and gender differences: an update. Transl Res. Corticosteroid therapy for patients with acute exacerbations of chronic obstructive pulmonary disease: a systematic review. Arch Intern Med. Respir Med. Prediction of the clinical course of chronic obstructive pulmonary disease, using the new GOLD classification: a study of the general population.
Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Bronchodilator delivery in acute airflow obstruction. A meta-analysis. Oral corticosteroids in patients admitted to hospital with exacerbations of chronic obstructive pulmonary disease: a prospective randomised controlled trial.
Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. N Engl J Med. Controlled trial of oral prednisone in outpatients with acute COPD exacerbation. Efficacy of corticosteroid therapy in patients with an acute exacerbation of chronic obstructive pulmonary disease receiving ventilatory support. Association of corticosteroid dose and route of administration with risk of treatment failure in acute exacerbation of chronic obstructive pulmonary disease.
Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial.
Miravitlles M, Anzueto A. Antibiotics for acute and chronic respiratory infections in patients with chronic obstructive pulmonary disease. Effect of high flow oxygen on mortality in chronic obstructive pulmonary disease patients in prehospital setting: randomised controlled trial. Gay PC. Complications of noninvasive ventilation in acute care.
Respir Care. Risk factors of hospitalization and readmission of patients with COPD exacerbation—systematic review. Readmissions for Chronic Obstructive Pulmonary Disease, Eisenhower C. Impact of pharmacist-conducted medication reconciliation at discharge on readmissions of elderly patients with COPD. Ann Pharmacother. Can the targeted use of a discharge pharmacist significantly decrease day readmissions? In this time, he occasionally had wheezing when breathing, but he noted no increase in shortness of breath.
The nurse advised him to be tested for coronavirus and scheduled a follow-up virtual visit for three days later. By then, his symptoms were worse. The cough was productive, associated with occasional mucoid expectoration, and now interfered with sleep. He said he still occasionally had wheezing on respiration but did not have worsened shortness of breath, fever, sore throat, myalgia or diarrhea.
Because he lacked transportation and social support, he could not undergo the recommended coronavirus test. He had never undergone pulmonary function testing at our institution and had never been hospitalized for similar concerns. On virtual examination, he appeared comfortable. His respiratory rate was 24 breaths per minute, and he did not appear to be using accessory muscles of respiration. No wheezing could be heard. Based on the impression that the patient was experiencing an acute exacerbation of COPD, 1 should he be prescribed a corticosteroid, and can this be done safely?
In acute exacerbations of COPD, systemic corticosteroids have been shown to accelerate improvement in airflow, delay the time to recurrence and, in hospitalized patients, reduce the length of stay. Virtual visits are appropriate during the pandemic, given the risk that a potentially infected individual poses to others. The use of virtual visits has expanded rapidly during the pandemic. However, a virtual assessment of a patient with COPD who is suspected of having an acute exacerbation is limited in some ways.
Another reason may be that there are fewer COPD exacerbations due to less air pollution because people are working from home and not traveling as much. Also, patients with chronic cough can be reflexively suspected of having COVID, and in-office visits are sometimes discouraged based on the infectious risk. Together, these factors have made virtual visits a mainstay of managing patients with COPD during the pandemic.
Virtual visits have provided a portal for healthcare access while mitigating infection risks. They can allow one to form a clinical impression and to decide whether the patient needs emergent, in-person care versus continued virtual management.
Though studies have examined the value of self-management strategies for COPD with online and telephonic backup, 5 to our knowledge no published report has specifically addressed best practices in virtual visit assessment of patients with COPD. A careful history is important to elicit a history of exposure to individuals known to have SARS-CoV-2, and also to assess whether the current illness resembles prior exacerbations the patient may have experienced.
Visual inspection is critical and plays an even more important role during a virtual visit. Because corticosteroids are indicated in acute exacerbations of COPD, the current case prompts two questions:. Notably, prednisone 40 mg is roughly equivalent to dexamethasone 6 mg in glucocorticoid potency, though the duration of treatment for a COPD exacerbation five days is less than that for severe COVID disease up to 10 days.
The patient was started on oral prednisone 40 mg for five days for what was presumed to be an acute exacerbation of COPD.
This case study explores the use of virtual visits in determining diagnosis and managing treatment. By Achintya D. Stoller, MD, MS. Cleveland Clinic is a non-profit academic medical center. Advertising on our site helps support our mission. We do not endorse non-Cleveland Clinic products or services Policy. This article is reprinted from Cleveland Clinic Journal of Medicine ;88[4] A year-old man with chronic obstructive pulmonary disease COPDusing an albuterol inhaler as needed, called our nurse triage line in October because his chronic cough had worsened over the past seven days.
In this time, he occasionally had wheezing when breathing, but he noted no increase in shortness of breath. The nurse advised him to be tested for coronavirus and scheduled a follow-up virtual visit for three days later.
By then, his symptoms were worse. The cough was productive, associated with occasional mucoid expectoration, and now interfered with sleep. He said he still occasionally had wheezing on respiration but did not have worsened shortness of breath, fever, sore throat, myalgia or diarrhea.
Because he lacked transportation and social support, he could not undergo the recommended coronavirus test. He had never undergone pulmonary function testing at our institution and had never been hospitalized for similar concerns. On virtual examination, he appeared comfortable. His respiratory rate was 24 breaths per minute, and he did not appear to be using accessory muscles of respiration.
No wheezing could be heard. Based on the impression that the patient was experiencing an acute exacerbation of COPD, 1 should he be prescribed a corticosteroid, and can this be done safely? In acute exacerbations of COPD, systemic corticosteroids have been shown to accelerate improvement in airflow, delay the time to recurrence and, in hospitalized patients, reduce the length of stay.
Virtual visits are appropriate during the pandemic, given the risk that a potentially infected individual poses to others. The use of virtual visits has expanded rapidly during the pandemic. However, a virtual assessment of a patient with COPD who is suspected of having an acute exacerbation is limited in some ways.
Another reason may be that there are fewer COPD exacerbations due to less air pollution because people are working from home and not traveling as much.
Also, patients with chronic cough can be reflexively suspected of having COVID, and in-office visits are sometimes discouraged based on the infectious risk. Together, these factors have made virtual visits a mainstay of managing patients with COPD during the pandemic. Virtual visits have provided a portal for healthcare access while mitigating infection risks. They can allow one to form a clinical impression and to decide whether the patient needs emergent, in-person care versus continued virtual management.
Though studies have examined the value of self-management strategies for COPD with online and telephonic backup, 5 to our knowledge no published report has specifically addressed best practices in virtual visit assessment of patients with COPD. A careful history is important to elicit a history of exposure to individuals known to have SARS-CoV-2, and also to assess whether the current illness resembles prior exacerbations the patient may have experienced.
Visual inspection is critical and plays an even more important role during a virtual visit. Because corticosteroids are indicated in acute exacerbations of COPD, the current case prompts two questions:.
Notably, prednisone 40 mg is roughly equivalent to dexamethasone 6 mg in glucocorticoid potency, though the duration of treatment for a COPD exacerbation five days is less than that for severe COVID disease up to 10 days. The patient was started on oral prednisone 40 mg for five days for what was presumed to be an acute exacerbation of COPD.
On follow-up one week after the initial virtual visit, his symptoms had dramatically improved, and he reported being back to his usual state of health. But despite the limitations, taking a systematic approach to the history and maximizing visual assessment, as with this patient, can help the patient safely get through the acute illness.
Although the efficacy of virtual visits has not been established for patients with COPD in general nor for those experiencing an exacerbation that might resemble COVID, this experience supports the value of virtual visits, coupled with a careful history and clinical observation during the visit. Antibiotic therapy in exacerbations of chronic obstructive pulmonary disease. Ann Intern Med. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease.
N Engl J Med. Azithromycin for prevention of exacerbations of COPD. Short-term vs conventional glucocorticoid therapy in acute exacerbations of chronic obstructive pulmonary disease: the REDUCE randomized clinical trial.
Eur Respir J. Respir Med. Accessed March 4, Philadelphia: WB Saunders; National Institutes of Health. November 3, Share this article via email with one or more people using the form below.
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In the past, the GOLD guidelines suggested the use of prednisolone 30 to 40 mg daily for 10 to 14 days. However, the most recent update. The administration of corticosteroids has long been a mainstay of therapy for the treatment of an acute exacerbation of COPD (AECOPD). In the past, the GOLD guidelines suggested the use of prednisolone 30 to 40 mg daily for 10 to 14 days. However, the most recent update. Notably, prednisone 40 mg is roughly equivalent to dexamethasone 6 mg in glucocorticoid potency, though the duration of treatment for a COPD. X Systemic corticosteroids for treatment of exacerbations Systemic corticosteroids reduce the severity of and shorten recovery from exacerbations. Infections and airway inflammation in chronic obstructive pulmonary disease severe exacerbations. Reproduction in whole or in part without permission is prohibited. Ventilatory Support: Some patients may require noninvasive nasal cannula or facial mask or invasive orotracheal tube or tracheostomy ventilatory support in order to maintain proper oxygenation. Ann Pharmacother.The number needed to treat to avoid one treatment failure is 9. There is no evidence that treatment with corticosteroids alters mortality. Unlike earlier reviews this review included four papers that compared intravenous corticosteroids with oral corticosteroids and two papers with ventilated patients in ICU.
In patients requiring ventilation in ICU, pooled data did not show a reduction in length of stay, duration of ventilation or mortality in those receiving corticosteroids compared with placebo Walters Walters et al concluded that there is no evidence of benefit for intravenous treatment compared with oral treatment with corticosteroids on treatment failure, relapse or mortality.
Hyperglycaemia rates were higher with intravenous corticosteroids. With regards to duration of treatment, a meta-analysis by Walters et al Walters concluded that five days of oral corticosteroids is likely to be sufficient [evidence level I]. In summary, a 5-day course of oral prednisolone of 30mg to 50mg is adequate. In patients who have been on oral corticosteroids for longer than 14 days, tapering may be necessary. Prevention and treatment of corticosteroid-induced osteoporosis should be considered.
Longer courses of prednisolone may increase mortality and pneumonia Sivapalan There is emerging evidence that blood eosinophil levels can be used as a biomarker to determine which patients require oral corticosteroids for exacerbations of COPD. A small, single centre, double blind randomised controlled trial used blood eosinophils as a biomarker to determine if prednisolone would be given for an exacerbation of COPD.
In the standard arm, all patients received prednisolone. The prednisolone dose was 30mg for 14 days and both groups received oral antibiotics. There was no difference in treatment failure or health status between the biomarker and standard groups Bafadhel Patients had blood eosinophil levels measured at the time of COPD exacerbation. The trial designs had considerable heterogeneity. Further, larger studies with long term follow up are required before any firm recommendations can be made.
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